Basic Information
Provider Information
NPI: 1033559935
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FRANK
FirstName: TIFFANY
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential: M.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2314 29TH ST APT 3
Address2:  
City: ASTORIA
State: NY
PostalCode: 111052897
CountryCode: US
TelephoneNumber: 5162970021
FaxNumber:  
Practice Location
Address1: 24302 NORTHERN BLVD
Address2:  
City: DOUGLASTON
State: NY
PostalCode: 113621150
CountryCode: US
TelephoneNumber: 7184236200
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/25/2013
LastUpdateDate: 08/08/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700X020746NYY Behavioral Health & Social Service ProvidersPsychologistClinical
103TC0700XP90273NYN Behavioral Health & Social Service ProvidersPsychologistClinical

No ID Information.


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